A Case of a New Immigrant Imagine that you are an immigrant arriving in a new country. Perhaps you are escaping persecution, famine, or war, or simply pursuing a

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Social Justice Brief CONTRIBUTORS: Brandy F. Henry, PhD(c), MA, LICSW Elizabeth Ringler-Jayanthan, LSW Dawn Brubaker, DSW Isabelle Darling, MSW Mel Wilson, MBA, LCSW Senior Policy Consultant National Association of Social Workers

Challenges of Refugee Resettlement Policy and Psychosocial Factors

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This social justice brief will discuss, analyze, and make policy recommendations about the process for obtaining refugee status and resettlement in the United States. We will also discuss the significant changes in the United States’ immigration and refugee policies that have adversely affected our nation’s commitment to providing a safe haven for the world’s displaced populations. Background There have always been migrants and refugees worldwide. However, the number of persons who are displaced, both internally and to another country, is currently at a historic high. Environmental, geothermal, and human conflict factors all contribute to the rise of migration. Each of these factors alone can cause migration; when combined they

increase abnormal migration. For example, environmental factors cause displacement and movement of people.2 Crop failure, for instance, can result in food scarcity, causing people to migrate to other countries for survivable living conditions. It is no surprise that human conflicts and violence are the main reasons for mass migration. At the end of 2014, war, violence, and persecution led to one in every 122 humans in the world becoming a refugee, becoming displaced, or seeking asylum.3 As reported by the United Nations refugee agency (UNHCR),4 the level of worldwide displacement has never been higher—with a record 59.5 million people having migrated from their homes at the end of 2014.

Challenges of Refugee Resettlement Policy and Psychosocial Factors

The issue of immigration is complex and includes many legal, social justice, and

psychosocial considerations. However, relatively little attention is paid to the

plight of refugees. A refugee is someone who has left his or her country

because of a well-founded fear of persecution, due to race, religion, nationality,

political opinion, or membership in a particular social group.1 In the United

States, to enter through the refugee resettlement program, one must be deemed

a refugee by the host country’s government, by the United Nations High

Commissioner for Refugees (UNHCR), or by both, before being given the

opportunity to be resettled in the United States.

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Additionally, in 2014 there were: » 19.5 million refugees, more than half of

them children » 38.2 million internally displaced people » 1.8 million asylum seekers.

Historically, the United States had always been a world leader in welcoming refugees. The Refugee Act of 1980 provided a formal process to actively bring refugees to the country when repatriation to the nation of origin was not possible.5 The resettlement process in the United States is managed by the U.S. Department of State’s Bureau of Population, Refugees, and Migration. The refugee resettlement program has historically had bipartisan support and at its core is a humanitarian program. During the start of the formal Refugee Resettlement and Placement program, the United States resettled refugees from Southeast Asia affected by the Vietnam War, as well as refugees from the Soviet Union and Eastern Europe. In more recent years, refugees from other parts of the world including Burma (Myanmar), Bhutan, Burundi, Sudan, Somalia, the Democratic Republic of the Congo, as well as Iraq, Syria, Afghanistan, Cuba, and Colombia have been resettled in the United States. The common goal of the resettlement program is to affirm America’s commitment to human rights. The overall hope underscoring the program is that those who are granted refugee status use their freedoms to demonstrate their appreciation for being granted refugee status by contributing to the economy and enriching the fabric of the community by bringing their cultural heritage and experiences to the United States.6

Definition of Refugee Resettlement Terms Refugee Resettlement Agency: Refugees are resettled across the United States by affiliate offices of the national resettlement agencies (also called voluntary agencies) that are contracted by the federal government to resettle refugees. At the affiliate level, case managers assist newly arrived refugees with service connection to adjust to their new communities and promote self-sufficiency. There are nine national agencies that facilitate the refugee resettlement process. Asylum Seeker: An asylum seeker is an individual who has left her or his country because of a well-founded fear of persecution, due to race, religion, nationality, political opinion, or membership of a particular social group, but has not been granted asylum status in the United States. People seeking asylum must go through the immigration court system before they can be considered for asylum, whereas refugees already have legal status when they arrive in the United States. Asylee: An asylee is an individual who has left her or his country because of a well-founded fear of persecution, due to race, religion, nationality, political opinion, or membership of a particular social group, and has been granted asylum to stay in the United States by an immigration court judge. Special Immigrant Visa (SIV) Holders: Iraqi and Afghan translators and interpreters working for the U.S. military and who meet certain requirements can qualify for the SIV program and receive refugee benefits in the United States.

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Cultural, Religious, and Ethnic Diversity of Refugee Migration As previously mentioned, for a variety of reasons there has been a significant increase in migration and refugees internationally. However, even in the face of a worldwide increase of displaced migrants, the United States has steadily decreased the number of refugees it accepts. In 2018, 22,491 individuals arrived in the United States as refugees,7 according to data from the State Department’s Worldwide Refugee Admissions Processing System. What is important about those data is that this represents a 58 percent decrease from the 53,716 admitted in 2017. The 2018 refugee number is also about half of the 45,000 admissions that were allotted for 2018. In 2019, Refugee Council USA is reporting that 26,345 have been resettled.8 To that point, about three-quarters of the refugees admitted in the first seven months of fiscal year 2019 were from Africa and East Asia,9 with refugees from the Democratic Republic of Congo and Burma (also known as Myanmar) being the top two demographic groups admitted thus far in 2019. It should be noted that Congolese refugees are fleeing many years of armed internal strife that has

killed more civilians than any war since World War II. With respect to Myanmar, tens of thousands of the ethnic Chin, Karen, and Muslim Rohingya have fled persecution by the government of Myanmar. These religious and ethnic groups have been allowed to resettle in the United States. Religious Factors in Admitting Refugees to the United States

The United States has admitted far more Christian refugees than Muslim refugees since fiscal year 2017.10 Refugees who identify as being Christians comprised 74 percent of refugees admitted to the United States thus far in 2019. During the first eight months of 2019, the United States admitted close to 22,300 Christians. This is compared with nearly 4,600 Muslims for the same period. These statistics warrant scrutiny because they indicate a marked reversal from previous years. For example, in 2016, Muslim refugees were admitted into the United States at a historic rate.11 In fact, in 2016, 38,900 Muslim refugees were resettled in this country, compared with about 37,500 Christian refugee admissions.

Refugees from conflict in the eastern Democratic Republic of the Congo leave the Nyakabande transit camp in Uganda. (Photo: Andy Wheatley/DFID)

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Emergence of Anti-Immigration Policies & Their Impact on Refugees It would be a mistake to understate the degree to which national immigration and refugee polices can affect the emotional and social stabilization of migrant populations. As alluded to in the background section, the international commitment to nations to accept and resettle refugees for humanitarian reasons had been a universal value. However, over the past three to five years, there has been a worldwide shift toward xenophobic anti-refugee policies often fueled by racial and religious intolerance. For instance, in 2015, the influx of refugees arriving in Europe sparked anger that created divisions across the continent.12 When Germany initiated a refugee program in 2015 that allowed more than one million migrants to claim asylum, there were domestic tensions from Germans who were adamantly anti-refugee. The United States has not been immune to international anti-refugee fervor. In fact, early in the Trump administration, key administrators advocated for anti-immigrant and anti-refugee polices. These policies have included those that severely limit immigrants’ ability to claim asylum in the United States, meant to deter and reduce asylum seekers in general, but specifically those from Central America claiming asylum, and to severely harshen conditions for those seeking asylum through inhumane conditions in detention centers. In addition, the administration has moved to end temporary protected status for 300,000 individuals from 10 countries (with the largest groups from El Salvador, Honduras, and Haiti), is attempting to end the DACA (Deferred Action for Childhood Arrivals) program and has ramped up Immigrations and Customs Enforcement raids nationwide.

Severe Reductions in Accepting Refugees in the United States

President Trump is also seeking to enact new rules designed to block refugees from reuniting with family members and to grind the resettlement process to a halt.13 Via an executive order,14 the administration will reduce the annual number of refugees admitted to the United States to 18,000 in the coming fiscal year. This policy move follows an administration trend of cutting refugee levels every year since 2016. In actuality, the administration considered dropping the cap to zero15 but backed away from that draconian reduction because of political pressure from Democrats and Republicans alike. This change will require the State Department to develop new procedures for refugee resettlement. Of concern to many refugee advocacy organizations is the fact that the order will require consent from states and localities before refugees can be resettled in their jurisdictions. Many refugee advocacy organizations16 find the explicit state and local consent requirement to be unnecessary. This is because current resettlement policies

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already ensure strong, active partnerships between state and local communities and resettlement agencies. The policy to cut refugee levels intersects with asylum-seeking families trying to reach the United States southern border. A recent Supreme Court ruling allowed the Trump administration to proceed with a broad ban on asylum seekers who travel through another country to get to the U.S.–Mexico border.17 The ruling will severely restrict access for tens of thousands of migrant families traveling north from Guatemala, El Salvador, and Honduras. The Trump administration has argued that asylum seekers (who apply from inside the United States or at the border) and refugees (who apply from abroad) draw from the same pool of federal resources.18 The administration has used that rationale to justify cutting refugee admissions in recent years as resources have been redirected to processing asylum requests. The Trump administration’s fiscal year 2019 refugee admissions ceiling is devastating for the refugee community in the United States and abroad. Since its first days in office, the Trump administration has taken calculated steps to severely restrict and weaken the U.S. refugee admissions program, the largest resettlement program in the world.19 Under the guise of strengthening national security, the administration first ordered a temporary 120-day ban on all refugees traveling to the United States,20 followed by a 90-day ban on refugees coming from 11 countries, including Syria and Somalia. The overt refugee admissions ban from all “high-risk” countries was lifted in early 2018, with the condition that refugees go through

additional security on top of the multiple— and highly effective—levels of screenings that have long been in place. Policies stifling the resettlement program are contrary to the beliefs of many national security experts who argue that strengthening the refugee system is in the national interest. Four decades of refugee admissions data from the U.S. Department of State Bureau of Population, Refugees, and Migration illustrate the extent of the reduction in refugee arrivals as well as the inordinately low admissions ceiling set by the Trump administration.21 For example, the refugee admissions ceiling was set at an average of 76,000 slots from fiscal years 1999 through 2016. In 2019, it was slashed to 30,000, a 64 percent reduction compared with 2016. In October 2019, President Trump issued a proclamation barring immigrants who do not have health insurance and cannot afford to pay medical care costs from getting visas (of almost any kind) to enter the United States.22 As mandated in the executive order, immigrants must be able to verify that they will obtain health insurance within 30 days of their arrival in this country or must prove that they will be able to pay for any medical expenses they incur once they enter the United States. The executive order lacks clear processes and procedures for determining whether immigrants meet these requirements. It appears that each individual consular officer will be responsible for evaluating visa applications by using loose criteria. The executive order seems to include most visa categories.23 For example, visa applicants who are parents and spouses of U.S. citizens and immediate family members

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of lawful permanent residents are also subject to the health insurance requirement. To justify the proclamation, Trump invoked the president’s power under the Immigration and Nationality Act,24 which allows the executive to “suspend the entry of all aliens or any class of aliens…or to impose on the entry of aliens any restrictions he may deem to be appropriate.” The Architects of Anti-Immigrant and Anti-Refugee Polices To many, the salient question is, why is the United States denying assistance to those who may be fleeing humanitarian disasters or are at imminent risk of violence?25. As a 2017 New Yorker report details,26 this hardline approach to immigration policy is reflective of the influence of Trump’s senior immigration adviser, Stephen Miller. The background about how the administration’s anti-immigration policies evolved is tied to a philosophical relationship between Stephen Miller and former attorney general Jeff Sessions, when the two became close allies on immigration policies, which pre-dates their joining the Trump presidential campaign. Sessions has long been a critic of undocumented immigrants and has pushed to curtail immigration to the United States.27 He spent much of his career in Congress fighting against immigration reform bills. In 2009, Stephen Miller joined Sessions as an adviser and assisted him in his anti-immigration efforts. For instance, when a major bipartisan immigration reform bill was introduced in 2013, Sessions was active in trying to kill it. When the bill passed the Senate, Miller wrote a 23-page handbook for House of Representatives members on

how to fight the bipartisan immigration reform deal.28 Soon after being elected, the Trump administration began to explore anti- immigration initiatives. In August 2017, a group of officials at the Department of Homeland Security gathered to brainstorm new ways to toughen immigration enforcement. Among those leading the discussion was an official who was a former aide to Jeff Sessions, then the attorney general. This individual was also a close associate of Stephen Miller, who by then had become Trump’s senior immigration adviser. – “Zero tolerance” emerged as the centerpiece immigration policy after that meeting, and the administration’s family separation policy was soon to follow.29 The Muslim Travel Ban As if zero tolerance and subsequent family separation policies were not enough, Miller became the lead architect and advocate for policies that banned individuals from designated countries from being admitted to the United States as refugees. Because most of the designated countries were primarily Muslim, the policy became known as the Muslim travel ban.30 Though implementing the ban became an unmitigated disaster, it set the stage for the Trump administration’s more aggressive efforts to greatly reduce the caps for refugee resettlement in the United States. The security threat narrative is based on a misunderstanding or willful misrepresentation of the refugee screening process. “Extreme vetting” already existed in that potential refugees to the United States go through a 20-step process that includes three fingerprint screenings, two background checks, and three extensive interviews, first by the UN

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Refugee Agency, then by the State Department, and finally by the Department of Homeland Security.31 This would explain why, of the more than three million refugees admitted to the United States from 1975 to 2015, only three have committed terrorist acts,32 with a total of three deaths. There has always been a screening process in place with an extreme vetting process beginning in 2011. None of the major mass shootings or terrorist acts in the United States in recent years—at San Bernardino, Boston, Orlando, and Las Vegas or on September 11—were carried out by refugees. In addition to this, the administration has attacked the formal refugee resettlement program administrated by the federal government. Under the Barack Obama administration, the “refugee ceiling,” or maximum number of refugees to be resettled for the year, was set at 110,000. Since then the ceiling has been drastically reduced each year, from 50,000 in 2017, to 45,000 in 2018 and in 2019 down to just 30,000. In January 2017, the Trump administration suspended refugee admissions for 90 days and enacted the “Muslim ban,” which halted refugee resettlement from 11 countries: Egypt, Iran, Iraq, Libya, Mali, North Korea, Somalia, South Sudan, Sudan, Syria, and Yemen. The ban has been referred to as a “Muslim ban” due to Islam being the majority religion practiced in these countries. In June 2018 the courts upheld this decision.

Positive Contribution of Resettled Refugees The downward trends in accepting refugees fly in the face of academic research that shows refugees having a net positive impact on public budgets. A National Bureau of Economic Research working paper finds that, on average, refugees to the United States pay $20,000 more per person in taxes than they receive in benefits.33 After being established in the country, they are more likely than equally educated U.S.-born citizens to be employed and less likely to be on welfare. Consider the following: » The average workforce participation rate

of refugees is 81.8 percent, well above the national rate of 62 percent.

» Refugees are more than twice as likely as U.S.-born workers to hold jobs in general or “other services”—a sector that includes a variety of service roles such as dry cleaning, housekeeping, and machine repair.

» Several industries rely heavily on refugee workers to support their economic stability. Refugees revitalize industries, and low rates of refugee arrivals significantly impair economic growth.

Unfortunately, recent policies34 imply that despite the added benefit that refugees bring to America (and other nations in the world), the seeds of anti-refugee and migrant sentiment have been sown internationally and domestically.

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Impact of Anti-Immigrant and Anti-Refugee Policies The impact of these policies is stark. Some individuals who were scheduled to be resettled in the United States may need to wait indefinitely for resettlement, and many will face continued hardship, possible violence, and even death. These individuals may have already been vetted by the United States and have been waiting for resettlement and now will need to wait indefinitely. There are families that are now split up, with one or more family members already resettled in the United States and others waiting to come. In addition, employers that frequently hire refugees have been unable to fill positions due to the low arrival numbers; landlords that frequently rent to newly arriving refugee families have also been affected. Finally, professionals who work in the field of refugee resettlement have been hit hard by closures of programs due to low arrival numbers, losing technical experience that those professionals have in administering these programs. Therefore, it is not surprising that refugee resettlement is an emotionally stressful process, especially for the new arrivals. Mental Health Impact of Migration and Resettlement When stress precipitated by ill-advised policies is coupled with the enormous amount of anxiety and apprehension caused by relocation, there is an increased probability of diagnosed mental health disorders within refugee communities. In talking about the emotional and mental health toll that refugee resettlement creates for individuals, families, and children, we are

referring to two factors: (1) the adjustments to culture and language that refugees are required to make once they are admitted into the United States; and (2) the fear and uncertainty that national policies such as the Muslim travel ban and the severe reduction in refugee admissions lead to in newly arriving refugees, making them feel unwanted and even despised. According to an analysis published in World Psychiatry, mental health practitioners work in an increasingly multicultural world, shaped by the migrations of people of many different cultural, racial, and ethnic backgrounds.35 People migrate for many reasons, whether political, socioeconomic, or educational. The richness of this diversity of cultures, ethnicity, races, and reasons for migration can make understanding experiences and diagnosis of illness challenging in people whose background and experience differ significantly from that of the clinician. Culture has an important role in the presentation of illness, and cultural differences have an impact on the diagnosis and treatment of migrant populations in part due to linguistic, religious, and social variations from the clinician providing care. In addition, it appears that the incidence and prevalence of psychiatric disorders varies among people of different cultural backgrounds due to an interplay of biological, psychological, and social factors. The provision of health care is necessarily influenced by the demands of people of many different cultures but relies on economic, social, and political factors, and it is important that cultural differences be appreciated and understood to arrive at a correct diagnostic impression and treatment plan.

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The migration process itself can be stressful, depending on the type and cause of migration, and can affect the mental health of migrating individuals and their families. Issues of cultural bereavement and identity occur with increased frequency among migrants and their families. Below we review these concepts and how they impinge on mental health and psychiatric care and, by so doing, help the clinician to identify these issues in a culturally sensitive way. Migration as a Precipitating Factor of Emotional Stress The process of migration has been described as occurring in broadly three stages.36 The first stage is pre-migration, involving the decision and preparation to move. The second stage, migration, is the physical relocation of individuals from one place to another. The third stage, post-migration, is defined as the “absorption of the immigrant within the social and cultural framework of the new society.”37 One hopes that social and cultural rules and new roles may be learned at this stage. The initial stage of migration may have comparatively lower rates of mental illness and health problems than the latter stages, due to the migrant’s younger age at the initial stage of migration. Problems with acculturation and the potential discrepancy between attainment of goals and actual achievement in the latter stages can lead to emotional problems. Many experts suggest that social adjustment and the prevalence of mental illness in migrants may be influenced by: » duration of the relocation » similarity or dissimilarity between the

culture of origin and the culture of settlement

» language and social support systems » acceptance by the majority culture » access to and acceptance by the

expatriate community » employment » housing

If individuals and families feel isolated from their culture, unaccepted by the majority culture, and lacking in social support, a consequent sense of rejection, alienation, and poor self-esteem may occur. Mental Health We must remember that migrants leave their countries of origin for traumatic reasons that often involve long and hazardous journeys. That, along with the process of resettlement in a new country and culture, increases the risk to a variety of mental health issues.38 Unfortunately, identification and treatment of mental health problems has lagged far behind screening for physical health problems. Exacerbating this gap in services is the general lack of evidence-based mental health treatment and interventions. The more common mental health diagnoses associated with refugee populations include: » post-traumatic stress disorder (PTSD) » major depression » generalized anxiety » panic attacks » adjustment disorder » somatization (a chronic feeling that one

has a physical ailment) Children and adolescents often have higher levels of diagnoses, with various studies revealing rates of PTSD from 50 to 90 percent and major depression from 6 to 40 percent.39 Risk factors for the development of mental

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health problems include the number of traumas, delayed asylum application process, detention, and the loss of culture and support systems. The resettlement process includes challenges such as the loss of culture, community, and language as well as the need to adapt to a new and foreign environment. Children are often caught between the old and new cultures because they learn new languages and acquire cultural norms more quickly than their older relatives. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), “Much work remains to be done to develop culturally competent means of screening refugees for mental health issues and then implementing evidence-based interventions, both at an individual and community level, for these common and frequently debilitating diagnoses.” Cultural Bereavement The loss of one’s social structure and culture can cause a grief reaction. Migration involves the loss of the familiar, including language (especially colloquial and dialect), attitudes, values, social structures, and support networks. Grieving for this loss can be viewed as a healthy reaction and a natural consequence of migration; however, if the symptoms cause significant distress or impairment and last for a specified period, psychiatric intervention may be warranted. Cultural bereavement is defined as the grief experience of the uprooted person—or group—resulting from loss of social structures, cultural values and self-identity. The person—or group—continues to live in the past, is visited by supernatural forces from the past while asleep or awake, suffers feelings of guilt over abandoning culture and homeland,

feels pain if memories of the past begin to fade, but finds constant images of the past (including traumatic images) intruding into daily life, yearns to complete obligations to the dead, and feels stricken by anxieties, morbid thoughts, and anger that mar the ability to get on with daily life.40 Such bereavement is triggered by many factors, but mainly by social, cultural, and economic issues. An example of manifested cultural bereavement is the reported case of an Ethiopian female refugee. Her symptoms of grief included her inability to perform her culturally sanctioned purification rituals because of her relocation and resettlement.41 The woman was regularly misdiagnosed because of the use of Western diagnostic criteria by clinicians who failed to consider that cultural displacement could be a major cause of her grief and depression. Such examples of misdiagnosis inform the SAMHSA recommendations about the need for culturally appropriate mental health interventions. Recommendations for Reforming the Resettlement Program Increasing the Ceiling for Admissions First and foremost, the refugee admissions ceiling must be restored to previous levels, and processing of those in the pipelines must resume. This is particularly necessary for those refugee groups who have been excluded due to the Muslim ban, which has effectively stopped all refugees from countries in need of help. Lengthening the Reception and Placement Period The reception and placement program are meant to provide a “soft landing” for newly arriving refugees. The progr

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